What is a Medicare opt-out provider?

A Medicare opt-out provider is an eligible practitioner who has formally opted out of Medicare and generally uses private contracts with Medicare beneficiaries for covered services, subject to CMS rules.

Opting out is a formal Medicare status and is not the same as simply being non-participating. A non-participating Medicare provider may still bill Medicare, while an opted-out practitioner follows the CMS opt-out framework and generally does not submit ordinary Medicare claims for covered services during the opt-out period. Billing staff should verify the provider’s actual Medicare status before deciding how to handle a service.

• Opt-out is a formal Medicare status.
• Opt-out differs from non-participating status.
• Private-contract requirements may apply.
• Medicare status should be verified before billing.

A physician says they are 'not participating with Medicare.' The credentialing team verifies whether the physician is actually non-participating or formally opted out before billing instructions are given.

• Confusing opt-out with non-participating status.
• Billing Medicare without verifying status.
• Assuming opt-out affects all payers the same way.

The key distinction is formal opt-out versus ordinary non-participating Medicare status.